Introduction: Optimal surgical management strategy of acute subdural hematoma (ASDH) patients remains challenging and rests mainly on the operating neurosurgeon based on intraoperative findings. We analyzed the association of decompressive craniectomy (DC) and osteoplastic craniotomy (OC) with outcomes in consecutive patients undergoing surgical evacuation of ASDH during a 7-year period, and analyzed prognostic indicators.
Methods: We reviewed prospective institutional database of all adult ASDH patients operated by craniotomy from January, 2009 until January, 2016. Mortality and discharge outcomes (Glasgow outcomes scale or GOS) were analyzed as a function of surgical method. Information pertaining to age, admission GCS, ASDH thickness and midline shift was also recorded.
Results: During the study period 394 (61%) patients underwent OC and 249 (39%) patients - DC. Patients needing DC were younger, had lower GCS, greater ASDH thickness and greater midline shift (p-values <0.001). Mortality rate (54% vs. 20%, respectively, p<0.001) and proportion of patients with poor discharge outcomes (85% and 45%, respectively, p<0.001) were greater in DC patients, relative to OC patients. GOS score was lower and mortality rate was greater (p-values=0.048) in DC patients, relative to OC patients across all patient subgroups. In patients with GCS score of 3 and midline shift of =2 cm outcomes were similar between the two groups. Adjusting for disease severity, DC remained associated with greater risk for in-hospital mortality (OR=3.442; [95%CI: 2.196-5.396], p<0.001) and unfavorable discharge outcome (OR=5.277; [95%CI: 3.030-9.191], p<0.001).
Conclusions: Decompression was performed more often in younger and more severely injured patients. DC is associated with greater mortality and handicap rates independently of disease severity. In patients presenting with worst clinical status, outcomes are poor irrespective of surgical method. Randomized controlled trials investigating clinical value of primary DC in ASDH patients are strongly encouraged.
Patient Care: The study shows that osteoplastic craniotomy should be considered over decompressive craniectomy when managing patients presenting with acute subdural hematoma.
Learning Objectives: 1. Decompressive craniectomy is more commonly performed in younger patients with greater trauma severity.
2. Decompression is associated with greater mortality and handicap rates independently of disease severity.
3. Osteoplastic craniotomy should attempted when possible.